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Background and objective Midshaft clavicular fractures were managed conservatively in the past, with a significant incidence of nonunion and poor functional outcomes in displaced fractures. Anatomically precontoured clavicle plates, since their introduction, have proved to be a superior method for managing these fractures. While open reduction and internal fixation of displaced clavicular fractures with plates have produced successful functional outcomes, complications like plate prominence, scar, postoperative numbness, wound dehiscence, refracture, and infection continue to discourage surgeons from plating these fractures. This study aimed to evaluate whether the precontoured 3.5-mm locking compression plate (LCP) for the clavicle is effective in the management of displaced clavicular fractures with minimum risk of complications. Methods A prospective observational study was conducted among 26 patients with displaced clavicular fractures that were managed with 3.5-mm precontoured LCP. The functional outcome was assessed by using the Constant-Murley Score (CMS) and healing was assessed radiographically six months postoperatively. Results Twenty-five patients were available for the final follow-up at the end of 24 weeks. All of them achieved excellent functional scores. The mean CMS was 94.9. No complication was observed in 85% of the cases. Implant failure was observed in both fractures of a bilateral clavicle fracture patient within a month of surgery. Implant irritation without prominence was seen in one patient and another had a prominent postoperative scar. The mean time for the radiological union was 13.8 weeks with union time ranging from three to five months. Conclusions Based on our findings, employing 3.5-mm precontoured clavicular LCPs is a useful technique that can provide good functional outcomes in displaced clavicular fractures.

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CONTEXT: Minimally invasive (MI) approaches are purported to present advantages for osteosynthesis when compared with conventional approaches. This study aimed to compare the medium-term clinical and radiological outcomes of patients with proximal humerus fractures treated by plate osteosynthesis with conventional and MI superolateral approaches. METHOD: The study carried out was a retrospective monocentric comparative analysis. Forty-three cases were followed up - 18 were treated with an MI approach and 25 with a conventional approach. Constant-Murley, DASH and SSV scores were established and standard complications were investigated. RESULTS: No significant differences in functional scores or complications were found between the 2 groups. The only significant difference was for pain which was significantly lower for the MI group. The overall revision rate was 18.3 %. The mean adjusted Constant-Murley for the entire population was 80.1 ± 20.2; the mean DASH score was 17.8 ± 15.9 and the mean SSV was 73.2 ± 19.5. CONCLUSION: This study did not demonstrate any significant differences between the 2 approaches. Given the low patient population in our series, the superiority of the MI approach - as indicated in the literature - was not proven.

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The present case report investigates the effectiveness of a progressive physiotherapy rehabilitation program in aiding the recovery of a patient who underwent biceps tenodesis. It is a surgical procedure involving the reattachment or relocation of the biceps tendon to alleviate pain and enhance function in conditions, like tendinitis or tears. The rehabilitation program is specifically tailored to address the distinct challenges associated with biceps tenodesis recovery, focusing on gradual exercises aimed at improving strength, range of motion (ROM), and functional capacity. Through a comprehensive analysis, this case report seeks to offer insights into the potential advantages and obstacles of employing a specialized physiotherapy approach in the holistic care of individuals undergoing biceps tenodesis, contributing to the ongoing development of postoperative rehabilitation strategies.

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IMPORTANCE: Partial-thickness rotator cuff tears (PTRCTs) commonly affect overhead athletes, leading to a decline in sports performance. Platelet-rich plasma (PRP) is being explored as an alternative treatment modality for individuals with PTRCTs to reduce discomfort and enhance functional recovery. We conducted a systematic review study of randomized controlled clinical trials to determine the effectiveness of PRP in treating PTRCTs. AIM: To determine the effectiveness of PRP in treating PTRCTs. EVIDENCE REVIEW: We conducted a comprehensive literature search for randomized controlled trials (RCTs) that compared the effectiveness of PRP with eccentric exercise and placebo injections as treatments for PTRCTs. We searched databases such as the Cochrane Library, Web of Science, PubMed, and EMBASE. The visual analog scale (VAS) score, American Shoulder and Elbow Surgeon (ASES) score, and Constant-Murley Score (CMS) was utilized as an outcome measure. Statistical analysis was performed using RevMan 5.3 software. FINDINGS: Our meta-analysis included 12 studies involving 762 patients. At six weeks post-treatment, the PRP group had significantly higher VAS scores compared to the control group, indicating improvement (standard mean difference (SMD): -2.04 [95% confidence interval (CI): -4.00 to -0.08], I2 â€‹= â€‹97%, P-value â€‹= â€‹0.04). Patients who received PRP showed statistically significant improvements in VAS scores at 3 months and 6 months follow-up (SMD, -1.78 [95% CI: -3.03 to -0.52], I2 â€‹= â€‹96%, P-value â€‹= â€‹0.005) (SMD: -2.26 [95% CI: -3.77 to -0.76], I2 â€‹= â€‹97%, P-value â€‹= â€‹0.003). A statistically significant difference was also observed in VAS scores at the long-term 1-year follow-up (SMD: -2.27 [95% CI: -4.07 to -0.47]; I2 â€‹= â€‹98%; P-value â€‹= â€‹0.031). There were statistically significant differences in ASES scores and CMS scores in the short-term (SMD: 1.21 [95% CI: 0.19 to 2.24], I2 â€‹= â€‹96%, P-value â€‹= â€‹0.02) (SMD, 2.01 [95% CI: 0.14 to 3.88], I2 â€‹= â€‹97%, P-value â€‹= â€‹0.04). However, in the long-term ASES and CMS scores did not show any statistical significance (SMD: 2.06 [95% CI: -0.54 to 4.65], I2 â€‹= â€‹99%, P-value â€‹= â€‹0.12) (SMD: 4.36 [95% CI: -5.48 to 14.21], I2 â€‹= â€‹99%, P-value â€‹= â€‹0.39). CONCLUSIONS AND RELEVANCE: Our findings suggest that PRP treatment is effective in reducing pain for individuals with PTRCTs, providing benefits in the short and long term. However, its impact on functional recovery appears somewhat constrained and doesn't endure over time. Additionally, significant heterogeneity exists among studies, encompassing variations in PRP composition and control group treatments. Consequently, we conclude that compelling evidence for symptom improvement in PTRCT patients following PRP treatment remains elusive. LEVEL OF EVIDENCE: Level I.

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Background: Although interest in studies evaluating the outcomes of rotator cuff repair is steadily increasing, the results and tendon integrity after arthroscopic rotator cuff repair in elderly patients have only been minimally investigated. The aim of this study was to evaluate clinical outcomes and repair integrity in patients over 65 years of age who underwent arthroscopic repair of full-thickness rotator cuff tears. Methods: A retrospective study was conducted with the following inclusion criteria: (1) elective shoulder arthroscopy for rotator cuff repair for full-thickness posterosuperior tears; (2) age over 65 years at surgery; and (3) participation in 24 months of follow-up. Preoperatively, the range of motion (ROM) and the Constant-Murley Score (CMS) and at follow-up, the ROM, the 12-Item Short Form Survey, the American Shoulder and Elbow Surgeons, and the CMS were evaluated; an ultrasonographic assessment of tendon integrity was performed according to the adapted Sugaya classification. Results: The final sample consisted of 110 patients with an average age of 69.2 ± 3.5 years. The mean duration of nonoperative management before surgery was 2.6 ± 0.8 months. The mean period of preoperative physical therapy was 0.6 ± 0.9 months. ROM and CMS showed statistically significant improvement (all P < .001) after a mean follow-up time of 54.5 ± 22.3 months. The ultrasonographic assessment showed tendon integrity (types I and II) in 75% of cases; 21% were type III repair, and rotator cuff retear (types IV and V) was recorded in 4% of cases. All scores directly correlated with the integrity of the tendon. In the multivariate analysis, higher postoperative CMS was associated with male sex (P < .001, ß = -6.085) and lower age (P = .004, ß = -0.533). Higher postoperative American Shoulder and Elbow Surgeons were associated with lower age (P = .020, ß = -0.414). Higher postoperative 12-Item Short Form Survey physical component score and mental component score were associated with lower age (P = .013, ß = -0.550 and P < .001, ß = -0.520, respectively) and shorter preoperative physical therapy period (P = .013, ß = -2.075 and P = .006, ß = -1.093, respectively). Conclusion: A significant ROM and CMS recovery and a rotator cuff integrity rate of 75% can be expected in patients over 65 years of age who undergo arthroscopic repair for full-thickness rotator cuff tears. Better functional, physical, and mental health outcomes correlate with rotator cuff integrity and are predicted by male sex and a shorter period of preoperative physical therapy.

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Background: The medium-term results of reverse shoulder arthroplasty (RSA) that has been performed by a single surgeon have been previously reported. The purpose of this study was to investigate the minimum 10-year clinical and radiographic outcomes of these patients. Methods: In this prospective cohort study, 27 patients were evaluated after RSA for massive rotator cuff tear with or without eccentric osteoarthritis (OA) or concentric OA with the Constant-Murley Score (CMS), range of motion (ROM), and a radiologic assessment. Results: At a mean 12-year follow-up, the CMS and ROM were significantly improved when compared with the baseline values (all P < .001). Once stratified by diagnosis, no difference in the ROM or total CMS was found between patients with massive rotator cuff tear with/without eccentric OA and those with concentric OA. Neither ROM nor CMS decreased when compared to the mid-term values of the previous study, for both the overall population and the diagnosis-stratified groups. Scapular notching was reported in 66.7% of cases that was similar to the data reported at mid-term follow-up. The calcification rate was 59.3% at the long-term evaluation, and there were no differences between the same case-series population (51.9%; P = .785) and the whole population at mid-term follow-up (47%; P = .358). Conclusion: RSA led to excellent clinical and functional outcomes for patients up to 17 years postoperatively, and there was no decrease in the CMS over time. No loosening of implants was noted, and the rate of scapular notching was 66%, mostly grade 1 or 2.

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Introduction The clavicle is the most unique long bone and has a significant incidence in terms of fractures. Operative fixation for clavicle fractures has seen a steep rise in terms of technique as well as type of implant. Although extensive studies have been carried out in relation to clavicle fractures and their treatment modalities, no proper guidelines or approach has been identified as ideal, and hence, this study was carried out to evaluate operative fixation as a viable strategy. Objective The objective of this article was to assess functional outcomes of plate fixation in clavicle fractures. Materials and methods This longitudinal prospective observational study included 30 patients treated for clavicle fractures with plate fixation in the Orthopedics Department of Himalayan Institute Hospital Trust (HIHT), Jollygrant, Dehradun, over a period of one year. Functional outcomes were assessed as Constant-Murley shoulder scores, and complications were recorded. Radiological assessment was done on the basis of time to union through follow-up skiagrams. Statistical analysis was performed using the SPSS statistical package version 17.0 (IBM Inc., Armonk, New York). Continuous variables are presented as mean ± SD, and categorical variables are presented as absolute numbers and percentages. Continuous variables and constant score values over time within the groups were analyzed using repeated measures analysis of variance (ANOVA) followed by Bonferroni's post hoc testing. A p-value of <0.05 was considered statistically significant. Results The mean age of patients undergoing surgical fixation of clavicle fractures was 36 ± 12.53 years, ranging from 18-65 years. Of the entire study group, 83.3% were males and 16.7% were females. Road traffic accident (RTA) was the most common cause of clavicle fracture, constituting 76.7% of the entire study population, followed by fall on the floor (20.0%), and one patient sustained trauma by being hit by a bull (3.3%). Our study demonstrated a mean Constant score of 73.87 ± 2.64, 82.80 ± 2.20, and 92.40 ± 2.37 at one-month, two-month, and four-month follow-up times, respectively, which was found to be statistically significant in terms of progression (p value<0.001). The mean union time of clavicle fractures in our study population was 12.1 weeks. Two patients in our study developed implant impingement. Conclusion Our study revealed that patients with clavicle fractures treated with plate fixation had statistically significant good functional outcome (Constant) scores at sequential follow-ups, consistent with available literature. Mean union time was also comparable to existing literature. Non-union was not noted in our study, and only two cases developed implant impingement. Hence, we conclude that early primary plate fixation for displaced clavicle fractures is a promising technique with good overall functional outcomes and patient satisfaction, especially in young, active patients.

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Proximal humerus fractures (PHFs) are a common type of fracture in adults. Although PHFs are common, bilateral presentation is extremely rare. Most PHFs are treated conservatively. In this report, we describe a 69-year-old right-hand-dominant male patient who was involved in a high-impact motor vehicle accident (MVA). The patient's upper limbs were in a fully extended position while he was holding the driving wheel, where he sustained a side impaction to the car by a hard object that caused bilateral four-part PHF with dislocation, which was confirmed on radiological investigations. The orthopedic surgery team believed that surgical treatment was necessary and ideal for these bilateral fracture dislocations, specifically bilateral reverse total shoulder arthroplasty (RTSA). This is due to multiple factors, including the risk of humeral head avascular necrosis (AVN), the patient's advanced age, low demand, poor bone stock, osteoporosis, and a non-fixable fracture pattern. The patient underwent a single-stage bilateral RTSA procedure, which was well tolerated. He was optimized postoperatively. The post-operative X-ray showed good and satisfactory implant positions and orientation. Functional assessment using the Constant-Murley Score (CMS) and Disabilities of the Arm, Shoulder and Hand (DASH) score were calculated at three-months follow-up (right-left: 50-60 and 41-14, respectively), at five-months follow-up (right-left: 34-66 and 38-14, respectively), and at eight-months follow-up (right-left: 40-68 and 24-7.5, respectively). Follow-up X-rays revealed good tuberosities healing, and no loosening or scapular notching. In addition, pain was assessed on a numerical rating scale (NRS), which demonstrated fast pain relief. Short-term follow-up with the patient demonstrated that he was satisfied with the surgery, especially the left side with a pain score on the NRS of one. We selected to share our experience of this complex case with our peers in the field of orthopedic surgery worldwide so that such a procedure could be implemented in similar cases to ensure satisfactory outcomes following bilateral four-part PHF with dislocation.

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Background: Accurate deltoid muscle assessment after reverse shoulder arthroplasty (RSA) is difficult using magnetic resonance imaging due to metal artifacts. We hypothesized that measuring the deltoid muscle area (DA) in the middle part of the deltoid's total length postoperatively would reduce metal artifacts and allow for an accurate assessment. This study aimed to assess the reliability and reproducibility of magnetic resonance imaging and evaluate its impact on postoperative outcomes. Methods: The DA in the middle part of the muscle's total length was measured twice by four examiners using pre and postoperative magnetic resonance imaging in 60 patients who underwent RSA (22 men, 38 women; mean age: 77.4 years). The DA at the greater tuberosity was measured preoperatively, and its correlation with the middle part of the deltoid's total length was evaluated. The Constant-Murley Score was measured at 2 years postoperatively, and its correlation with the DA in the middle part of the deltoid's total length pre- and postoperatively was assessed. Results: Intraclass correlation coefficients for intraobserver measurements of preoperative and postoperative DA in the middle part of the deltoid's total length were almost perfect, with mean values of 0.98 and 0.97, respectively. The intraclass correlation coefficients for interobserver reliability regarding the first and second DA measurements in the middle part of the deltoid's total length were 0.95 and 0.95 (preoperatively) and 0.89 and 0.90 (postoperatively). The Constant-Murley Score was assessed at 2 years postoperatively in 51 patients. Muscle strength was weakly and moderately correlated with preoperative DA (r = 0.33, P = .02) and postoperative DA (r = 0.49, P < .01), respectively. Conclusion: DA measurement in the middle part of the deltoid's total length after RSA was not affected by metal artifacts and had excellent reproducibility. This measurement method positively correlated with postoperative muscle strength, suggesting its usefulness for predicting postoperative muscle strength.

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BACKGROUND: Literature describing outcomes and integrity after isolated subscapularis (SSC) tendon repair is emerging but remains limited to a few small case series with short-term follow-up. The aim of this study was to evaluate the long-term clinical outcomes and repair integrity in patients who underwent arthroscopic repair of isolated SSC tears. METHODS: A retrospective study was conducted with the following inclusion criteria: (1) primary and elective shoulder arthroscopy for isolated SSC repair, (2) type III (a full-thickness tear in the upper two-thirds of the tendon) or IV (a complete tear without tendon retraction) SSC tear according to the Lafosse classification, and (3) a minimum 24-month follow-up. Preoperatively, the range of motion (ROM) and the Constant-Murley score (CMS) and at follow-up, the ROM, the University of California-Los Angeles (UCLA) Shoulder Rating Scale, the Disabilities of the Arm, Shoulder, and Hand (DASH) questionnaire, and the CMS were evaluated; an ultrasonographic assessment of tendon healing was performed according to the Sugaya classification. RESULTS: The final sample consisted of 45 patients with an average age of 55 ± 9 years. After a mean follow-up time of 107 ± 54 months, the mean UCLA and DASH scores were 8.7 ± 1.3 and 42.2 ± 6.4, respectively. ROM and CMS showed statistically significant improvements (all P < .001). Before surgery, the mean CMS was 49% that of sex- and age-matched healthy individuals, and all patients showed a CMS lower than the normative data. At the final follow-up visit, the mean CMS was 94.2% that of sex- and age-matched healthy individuals, and no patients showed CMS of 30 or less. The mean increase in the CMS was 41.4 ± 9.8 points (range, 23-60 points). The ultrasonographic assessment showed SSC tendon healing in 39 (86.7%) cases; tendon retear was recorded in 5 (13.3%) cases. All scores directly correlated with the healing of the tendon. A higher postoperative DASH score was associated with male sex (P = .039, ß = 5.538) and a longer follow-up period (P = .044, ß = 0.001). The postoperative CMS (P < .001) and UCLA scores (P = .001) were significantly higher in patients younger than 60 years of age at surgery than in older individuals. CONCLUSION: Arthroscopic repair of isolated SSC tears achieves excellent clinical and functional results at a mean of 9 years postoperatively, with a satisfactory healing rate. Better functional outcomes correlate with SSC tendon integrity and were observed in male patients and in those younger than 60 years at surgery.

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This systematic review aims to assess the contemporary literature on the incidence rate, functional scores, and clinical outcomes of heterotopic ossification (HO) following shoulder arthroplasty. We conducted a thorough literature search on EMBASE, MEDLINE, and Ortho Search to identify studies that directly compared patients with and without HO following hemiarthroplasty, anatomic total shoulder arthroplasty (aTSA), or reverse total shoulder arthroplasty (rTSA). We included studies with a minimum follow-up period of one year published from January 2000 to March 2023. We excluded case reports, editorials, and reviews. We performed the systematic review in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Of the 297 studies initially identified, seven met our inclusion criteria. These studies evaluated a total of 1,134 arthroplasties (212 hemiarthroplasties, 376 aTSAs, and 546 rTSAs). The mean follow-up period was 30.52 (12-120) months and the mean age was 68.69 (20-92). The overall incidence rate of HO was 26.8% (304/1,134). Male gender was associated with a higher incidence rate of HO in three studies. No statistically significant difference was noted in symptoms at follow-up or in Constant-Murley score at two years of follow-up (HO vs. non-HO: 70 vs. 75, p = 0.081). Only one study reported a significant difference in the post-arthroplasty range of motion, specifically in forward elevation (121° vs. 133°, p = 0.0087) and external rotation (19° vs. 25°, p-value = 0.0266). We conclude that HO after shoulder arthroplasty does not display a significant impact on postoperative symptoms or functional outcomes in the majority of patients. To fully comprehend its effect, further research and consensus among experts is necessary.

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BACKGROUND: Plate osteosynthesis with implants made of carbon-fibre-reinforced polyetheretherketone (CFR-PEEK) has recently been introduced for the treatment of fractures of the proximal humerus (PHFs). The advantages of the CFR-PEEK plate are considered to be its radiolucency, its favourable modulus of elasticity, and the polyaxial placement of the screws with high variability of the angle. The primary aim of this study is to investigate the influence of calcar screw positioning on the complication and revision rates after CFR-PEEK plating of PHFs. The secondary aim is to assess its influence on functional outcome. MATERIAL AND METHODS: Patients were identified retrospectively. Minimum follow-up was 12 months. The cohort was divided into two groups depending on the distance of the calcar screw to the calcar (group I: < 12 mm, group II: ≥ 12 mm). The range of motion (ROM), Subjective Shoulder Value Score (SSV) and Constant-Murley Score (CS) were analysed at follow-up examination. Subjective complaints, complications (e.g. humeral head necrosis, varus dislocation) and the revision rate were evaluated. RESULTS: 51 patients (33 female, 18 male) with an average age of 68.6 years were included after a period of 26.6 months (group I: 32 patients, group II: 19 patients). Apart from the gender distribution, no significant differences were seen in the patient characteristics. The outcome scores showed significantly better clinical results in group I: SSV 83.4 vs 71.2, p = 0.007; CS 79.1 vs 67.8, p = 0.013. Complications were seen less frequently in group I (18.8 % vs 47.4 %, p = 0.030). CONCLUSION: This study shows that the positioning of the calcar screw is relevant for CFR-PEEK plate osteosynthesis in PHFs with a good reduction of the fracture. Optimal positioning of the calcar screw close to the calcar (< 12 mm) is associated with a lower rate of complications, resulting in significantly superior functional outcomes. LEVEL OF EVIDENCE: III, retrospective cohort study.

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PURPOSE: No therapeutic intervention is universally accepted for frozen shoulder, and the most effective management to restore motion and diminish pain has yet to be defined. The aim of this study was to investigate functional and psychological outcomes in patients who underwent arthroscopic capsular release for a frozen shoulder. METHODS: A retrospective study with prospective data collection was conducted with 78 patients suffering from frozen shoulder resistance to conservative treatment. Considering the etiology, there were 36 (46.2%) idiopathic, 31 (39.7%) postoperative, and 11 (14.1%) posttraumatic cases. Preoperatively, each patient was evaluated with the range of motion (ROM) assessment and the Constant-Murley score (CMS). At follow-up, the 4-point subjective satisfaction scale (SSS), the ROM assessment, the SF-12 questionnaire, the numerical rating scale (NRS) for the subjective assessment of pain, the CMS and the Hospital Anxiety and Depression Scale (HADS) were assessed. RESULTS: After a mean follow-up of 54.2 ± 22.3 months, ROM and CMS showed a statistically significant improvement between pre- and postoperative values (all p < 0.001). Before surgery, the mean CMS was 36.9% that of sex- and age-matched healthy individuals, and all patients showed a CMS lower than the normative data. At the final follow-up visit, the mean CMS was 99.9% that of sex- and age-matched healthy individuals, and 49 (62.8%) patients showed a CMS equal to or higher than the normative data. The mean increase in the CMS was 56.1 ± 8.3 points. The mean SSS, HADS-A, HADS-D, and NRS were 3.7 ± 0.5, 2.5 ± 1.6, 2.2 ± 1.3, and 2.2 ± 1.0, respectively. All patients returned to their previous level of work and sports activity after 2 and 2.5 months, respectively. The multivariate analysis showed the association between a higher postoperative CMS and the idiopathic etiology of a frozen shoulder (p = 0.004, ß = 3.971). No intraoperative complications occurred. Postoperatively, four patients (5.1%) were treated with intra-articular steroid injections to manage residual symptoms. One patient (1.3%) with a postoperative frozen shoulder showed persistent symptoms and underwent a new successful arthroscopic capsular release. CONCLUSION: High patient satisfaction and statistically significant ROM and CMS recovery can be achieved after arthroscopic capsular release to manage frozen shoulder. Better functional outcomes are expected when the etiology is idiopathic. Results can help surgeons identify the patients who will most benefit from surgery and should be discussed with the patient. LEVEL OF EVIDENCE: III.

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Although rotator cuff injures are often associated with a limited range of motion and muscle weakness, being able to conduct pain-free and efficient performances of the activities as part of daily living seems to be more important for patients. The aim of this study was to investigate the correlation between two questionnaires-the disease-specific, subjective questionnaire termed the Western Ontario Rotator Cuff Index (WORC), and the shoulder-specific, subjective-objective questionnaire Constant-Murley score (CMS), with the objective assessment of external rotator muscle strength, and the subjective assessment of pain according to the visual analog scale (VAS) in patients after arthroscopic rotator cuff repair. The study was carried out among 47 patients twice-6 and 12 months after surgery, respectively. All patients completed the WORC, the CMS, and the VAS. Isokinetic evaluation of the external rotators was performed using the Biodex 4 ProSystem. The correlations of all assessed muscle strength parameters with both the CMS and the WORC were found to be statistically significant, being mostly average during the 1st examination and mostly strong during the 2nd examination. There was a significant improvement in all assessed tools as a result of the undertaken rehabilitation. There were weak correlations present between changes in the WORC and changes in the external rotator muscle strength, with correlations between WORC-Sport and EXT900-AVERAGE-POWER and PEAK-TORQUE also being found statistically significant. Correlations of changes in the CMS scale with changes in the external rotator muscle strength were weak and statistically insignificant. It seems that the WORC questionnaire can be recommended more for the population after rotator cuff repair, which allows for a reliable assessment of patients' ability to function and its changes in various areas of life, and at the same time does not require a direct assessment by a clinician or researcher.

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BACKGROUND: The Constant-Murley Score (CMS) is one of the most employed tools for assessing shoulder function. It was first devised in 1987 for the English population and is now widely used internationally. However, it had yet to be cross-culturally adapted and validated to Spanish, which is the world's second-most native language. Formal adaptation and validation of clinical scores is paramount for them to be used with rigorous scientific methodology. METHODS: Following international recommendations for the cross-cultural adaptation of self-report measures, the CMS was first adapted into Spanish in six stages: translation, synthesis, back-translation, a review by expert committee, pretesting, and final appraisal by expert committee. After conducting a pretest with 30 individuals, the Spanish version of the CMS was tested on 104 patients with various shoulder pathologies to assess content, construct, criterion validity, and reliability. RESULTS: No major conflicts were encountered in the process of cross-cultural adaptation, with 96.7% of pretested patients having a full understanding of every item in the test. The validation showed excellent content validity (content validity index = .90), construct validity (strong correlation between items within the same subsection of the test), and criterion validity (CMS - Simple Shoulder Test, Pearson r = .587, P = .01; CMS - American Shoulder and Elbow Surgeons, Pearson r = .690, P = .01). Reliability of the test was also excellent, with high internal consistency (Cronbach's α = .819), interrater reliability (intraclass correlation coefficient = .982), and intrarater reliability (intraclass correlation coefficient = .937), without showing ceiling or floor effects. CONCLUSION: Spanish version of the CMS has been proved to accurately reproduce the original score and to be easily comprehensible by native Spanish speakers with acceptable intrarater-interrater reliability and construct validity. INTRODUCCIóN: La escala de Constant-Murley (CMS) es una de las más empleadas para evaluar la función del hombro. Se ideó por primera vez para la población inglesa en 1987 y actualmente es ampliamente empleada a nivel internacional. Sin embargo, su validación y adaptación transcultural no se han realizado al español, la segunda lengua nativa más hablada en el mundo. Actualmente no puede resultar admisible el empleo de escalas en las que no tengamos la seguridad de que existe una equivalencia conceptual, cultural y lingüística entre la versión original y la empleada. MATERIAL Y MéTODO: La versión traducida al español de la CMS se realizó siguiendo las recomendaciones internacionales: traducción, síntesis de la traducción, retrotraducción, revisión por comité de expertos, pretest y validación. Tras la realización del pretest en 30 individuos, la versión española de la escala de CMS se probó en 104 pacientes con diferentes patologías de hombro para evaluar las propiedades psicométricas de la escala: contenido, constructo, validez de criterio y fiabilidad. RESULTADOS: No se encontraron problemas importantes durante el proceso de adaptación transultural con un entendimiento completo de todos los ítems del pretest por el 96.7% de los pacientes. La escala adaptada demostró una excelente validez de contenido (índice de validez de contenido = .90), de constructo (fuerte correlación entre ítems de la misma subsección del test), y de criterio (CMS-SST Pearson's r = .587, p = .01; CMS-ASES Pearson's r = .690, p = .01). La Fiabilidad del test resultó excelente, con una elevada consistencia interna (Cronbach's α = .819), fiabilidad interobservador (ICC = .982) e intraobservador (ICC = .937), sin efectos techo y suelo. CONCLUSIóN: La versión Española de la CMS garantiza la equivalencia con respecto al cuestionario original. Los presentes resultados, sugieren que esta versión es válida, fiable y reproducible para la evaluación de la patología de hombro en nuestro entorno.

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Background: There is still no gold standard treatment for Neer type V distal clavicle fractures. This study was designed to evaluate the therapeutic effects of accelerated rehabilitation in treating Neer type V fractures using anatomical locking plate (ALP) fixation with additional coracoclavicular (CC) ligament augmentation. Methods: In this retrospective study, patients who underwent ALP fixation with additional suture anchor fixation of acute Neer type V distal clavicle fracture from January 2016 to January 2021 were reviewed. Injury radiography and computed tomography (CT) were performed to determine the Neer classification. All patients performed standardized early rehabilitation exercises after surgery and were followed up for more than 12 months. The Constant-Murley score (CMS); the disabilities of the arm, shoulder, and hand (DASH) questionnaire; visual analog scale (VAS); and the percentage of modified CC distance (MCCD%) were evaluated at the last follow-up. Results: Thirty-two patients were included in this study. The mean follow-up time was 31.1 ± 10.4 months. All patients achieved bone union 6-8 weeks (7.2 ± 0.7 weeks) after surgery and were allowed to return to normal daily life. No surgery-related complications occurred in any case. The MCCD% value at the last follow-up (104.7% ± 8.5%) significantly decreased compared with preoperative MCCD% value (162.8% ± 7.2%) (p < 0.001), indicating that all patients achieved ideal fracture reduction. And all patients obtained satisfactory shoulder joint function with a mean CMS of 97.1 ± 2.6, a mean DASH score of 1.6 ± 1.3, and a mean VAS score of 0.4 ± 0.6. Conclusion: This study has demonstrated that ALP fixation with additional suture anchor fixation is a promising strategy for accelerated rehabilitation in treating patients with Neer type V fracture.

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Background: Loss of internal rotation remains an issue after reverse total shoulder arthroplasty (RTSA). Our goal is to define the expected functional internal rotation after RTSA using the Activities of Daily Living which require Internal Rotation (ADLIR) score in a homogenous population of patients treated with RTSA. Methods: 35 patients with a minimum follow-up of two years after RTSA were evaluated using the ADLIR and Constant-Murley questionnaires. A correlation between the ADLIR and Constant score was investigated and the internal validity of the ADLIR score used in a RTSA patient population was measured using Cronbach's alpha coefficient. The impact of internal rotation on the total rotational arc of motion was defined. Results: Excellent results were recorded for both the Constant score (79 ± 18) and ADLIR score (88 ± 16). Pearson's correlation coefficient was r = 0,84 (p-value <0,001). The ADLIR score showed a high reliability for all questions. Conclusions: The ADLIR score has proven to be a useful addition in the post-operative evaluation of patients treated with RTSA. Further studies are needed to investigate the evolution of the ADLIR score from pre- to postoperatively in order to determine the clinical and predictive value of this score. Level of evidence: Level IV - Observational study.

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Objectives: The aim of this study was to translate, cross-culturally adapt the patient-based Constant-Murley Score (p-CMS), assess its validity, reliability, and compare it with the clinician-based CMS (c-CMS). Patients and methods: This cross-sectional study included a total of 51 shoulders of 46 patients (22 males, 24 females; mean age: 49±10 years; range, 29 to 70 years) with shoulder pain between December 2015 and July 2016. After translation of p-CMS, each participant was asked to complete the final Turkish version of the p-CMS. The c-CMS was assessed by a physiatrist who was blinded to the p-CMS. Retest of the p-CMS was performed in patients (n=15) who did not receive any treatment between two visits (Days 3 to 5). Results: A total of 51 shoulders (n=5 bilateral shoulder pain) were tested. Strength, subjective, objective, and total scores were significantly different between the p-CMS and c-CMS (p<0.001). Pain scores of the c-CMS and p-CMS revealed similar results with 95% limits of agreement of -3.81 and 4.81. Weighted kappa statistics demonstrated that the levels of agreement ranged between 0.343 and 0.698 in subjective and between 0.379 and 0.515 in objective components. For test-retest reliability of the p-CMS, intraclass correlation coefficient values ranged between 0.838 and 0.995. Conclusion: The Turkish version of the p-CMS has internal consistency and test-retest reliability to evaluate shoulder function in Turkish patients with shoulder pathologies. Considering the differences in test protocols and scoring methods of c-CMS and p-CMS, their interchangeable use is not supported.

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Background: To investigate the clinical value of ultrasound (US)-guided intervention for frozen shoulder (FS) in the frozen stage. Methods: This study included 40 patients who had primary FS in the frozen stage and were evaluated by US. These 40 patients have all received conservative treatment elsewhere, and no satisfactory results have been achieved, with no improvement in active and passive movement angles, and no improvement in scores within 3 months. Therefore, their previous treatment was set as comparison. All patients underwent US-guided shoulder joint capsule distension by injection of sterilized water. Of these participants, 22 patients with scapulohumeral periarthritis received a compound betamethasone injection, and 14 patients with thickened coracohumeral ligaments (CHLs) underwent acupotomy lysis, and the remaining 4 patients had no extra treatments. The Constant-Murley score (CMS) was evaluated before and after the operation and analysed for each patient. Results: Before treatment, the indices for the thickening of the subaxillary joint capsule, subacromial bursa (with or without effusion), long head of the biceps brachii tendon (LHBBT) and CHL were 40, 22, 16 and 14, respectively. After treatment, all the indices were significantly decreased (all P < 0.010) except for that of the LHBBT (P = 0.123). The patients' CMSs improved, with the median total CMS increasing from 59 points (interquartile range: 53-64 points) to 86 points (interquartile range: 78-90 points) (P < 0.010). While the internal rotation (Ir) of the shoulder joint did not improve (FDRs < 0.50), abduction, forward flexion (Ff) and external rotation (Er) improved significantly (all FDRs = 1.00). Conclusion: Compared with conservative treatment, US-guided intervention for FS in the frozen stage is highly effective and of great clinical value.

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BACKGROUND: Two common ways of assessing the clinical relevance of treatment outcomes are the minimal important difference (MID) and the patient acceptable symptom state (PASS). The former represents the smallest change in the given outcome that makes people feel better, while the latter is the symptom level at which patients feel well. METHODS: We recruited 124 patients with a humeral shaft fracture to a randomised controlled trial comparing surgery to nonsurgical care. Outcome instruments included the Disabilities of Arm, Shoulder, and Hand (DASH) score, the Constant-Murley score, and two numerical rating scales (NRS) for pain (at rest and on activities). A reduction in DASH and pain scores, and increase in the Constant-Murley score represents improvement. We used four methods (receiver operating characteristic [ROC] curve, the mean difference of change, the mean change, and predictive modelling methods) to determine the MID, and two methods (the ROC and 75th percentile) for the PASS. As an anchor for the analyses, we assessed patients' satisfaction regarding the injured arm using a 7-item Likert-scale. RESULTS: The change in the anchor question was strongly correlated with the change in DASH, moderately correlated with the change of the Constant-Murley score and pain on activities, and poorly correlated with the change in pain at rest (Spearman's rho 0.51, -0.40, 0.36, and 0.15, respectively). Depending on the method, the MID estimates for DASH ranged from -6.7 to -11.2, pain on activities from -0.5 to -1.3, and the Constant-Murley score from 6.3 to 13.5. The ROC method provided reliable estimates for DASH (-6.7 points, Area Under Curve [AUC] 0.77), the Constant-Murley Score (7.6 points, AUC 0.71), and pain on activities (-0.5 points, AUC 0.68). The PASS estimates were 14 and 10 for DASH, 2.5 and 2 for pain on activities, and 68 and 74 for the Constant-Murley score with the ROC and 75th percentile methods, respectively. CONCLUSION: Our study provides credible estimates for the MID and PASS values of DASH, pain on activities and the Constant-Murley score, but not for pain at rest. The suggested cut-offs can be used in future studies and for assessing treatment success in patients with humeral shaft fracture. TRIAL REGISTRATION: ClinicalTrials.gov NCT01719887, first registration 01/11/2012.

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